Main duties of the job * Utilise population health intelligence to proactively identify and work with a cohort of patients to deliver personalised care; * Support patients to utilise decision aids in preparation for a shared decision-making conversation; * Holistically bring together all of a persons identified care and support needs, and explore options to meet these within a single personalised care and support plan (PCSP), in line with PCSP best practice, based on what matters to the person; * Help people to manage their needs through answering queries, making and managing appointments, and ensuring that people have good quality written or verbal information to help them make choices about their care, using tools to understand peoples level of knowledge, confidence in skills in managing their own health; e. support people to take up training and employment, and to access appropriate benefits where eligible for example, through referral to social prescribing link workers; * Work with the GPs and other primary care professionals within the PCN to identify and manage a caseload of patients, and where required and as appropriate, refer people back to other health professionals within the PCN; * Raise awareness within the PCN of shared decision-making and decision support tools; * Raise awareness of how to identify patients who may benefit from shared decision making and support PCN staff and patients to be more prepared to have shared decision-making conversations.